QPR for Farmers and Ranchers: Preventing Rural Suicides

1. QPR for Farmersand RanchersInstructions to QPR Instructors: Use any or all of these slides to teach QPR for Farmers/Ranchers. They should go up front – talking points are provided. Your name here QPR Institute

2. Farmers at risk?

3. Farmer’s suicide note to wife… “The only thing I will regret is leaving the children and you. This farming has brought me a lot of memories, some happy, but most of all grief. The grief has finally won out – the low prices, bills piling up, just everything. The kids deserve better and so do you. I just don’t know how to do it. This all I know it’s just no good anymore.” Found at: htpp://www.omh.state.ny.us/omhweb/suicide_prevention/rural/farm_net.html cited by Idaho Suicide Prevention Research Project, 2009

4. Facts • Suicide rates are higher in rural areas • US suicide rate = 13/100,000 per year • US male suicide rate = 20/100,000 per year • Male farmer suicide rate = 34/100,000 (in 2008 –see next slide) • Female farmer suicide rate = 6/100,000 (same as general female rate) Source: Browning, Westneat & McKnight, 2008 (Idaho famers)

5. But! A new 2016 CDC Report found.. - The highest suicide rates by occupation in America are among farming, fishing, and forestry. How high? - There are 90 deaths per 100,000 for men in these professions, compared to a national average of 16 deaths by suicide per 100,000 for the general population. - This means suicide rates among famers are six times higher than the national average, and almost all of them are male. - The female farmer rates = national average)

6. How do they die? • In countries where they are available, firearms are the most common means. • In countries where firearms are scarce, e.g., India, other methods increase and especially hangings. Source: Hawton et. Al., 1999, Liu & Waterbor, 1995, and Stallones, 1990

7. Unique stressors • Losing the farm/ranch - foreclosures of mortgages • Health crisis and especially disabling injury • Weather related crop loss • Machinery breakdown related crop loss • Raising livestock produces more stress than crops • Older farmers report higher stress levels • Women farmers report higher stress than men Source: Freeman, Schwab & Jiang, 2008

8. The usual suspects put male farmers at high risk… • Being male is a barrier to health care • Cannot ask for help • Limited access to health care • Multiple uncontrollable stressors e.g., weather, prices, and regulations • Lack of close confident • Stress-driven onset of depressive disorder • Alcohol abuse

9. Suspicious finding but no data Several researchers have cited the long term exposure to agricultural chemicals such as pesticides that may impact serotonin levels in the brain and increase the risk for mood disorders among famers…. Source: Idaho Suicide Prevention Research Project

10. Seasonality • Farmers are much more likely to take their own lives during spring planting or fall harvest. • It is not clear why this occurs, although farmers are strongly tied to the seasonal cycle and may be responding to the stresses during these periods of the year. Source: Beeson, 2007

11. Nature of farm work… • Financial stress is always present, pressure to never lose the family farm is great, the work is physically and mentally stressful with long hours, social isolation and lack of confiding relationships. Add to this the onset of mood disorders that go untreated and reluctance to seek help, and you have a formula to set up the necessary conditions for a suicidal behavior.

12. Prevention • Researchers report finding no farmer-specific suicide prevention programs anywhere on the planet, although England and Australia have many local farmer support groups. • The California Farm Bureau Farm Stress webpage offers suicide prevention resources. • QPR Instructors are training farm families in New Zealand, the US, and Ireland with good reception and results.

13. Note A new study from Australia suggests that while 6 in 10 suicidal farmers communicated intent to die by suicide before killing themselves, “a considerable number of men” had no “current or past psychiatric conditions” – suggesting that encouraging mental health help-seeking may not be an effective suicide prevention strategy for many farmers. McPhedran & De Leo, Suicide & Life-Threatening Behavior, December 2013

14. From Theory to Practice: Focus on men since that’s who is doing the most dying… • Why farmers don’t ask for help – a reality check • Why accepting help is better than asking for it • Why competency-based training matters • Who should we train and how?

15. Old rural value: Accepting help is a good thing, not a bad thing

16. Suicidal Farmers and Ranchers Those most at risk for suicide are the least likelyto ask for help. Thus, we must find these men and help them where they are – and they are NOTin our mental health offices. If we expect male farmers and ranchers to ask for help to get it, they will continue to die.

17. Ideal treatment would be…. • Completely Confidential • Easily accessible • Affordable or free • Safe and effective • Easy to find – a mouse click away • Require no transportation • Delivered by “like me” professionals (helpers who know farmers and ranchers and “get it.”)

18. Orientation to QPR Gatekeeper Training for those who know and love farmers and ranchers Goals • What is QPR? • Why is it important? • How does it work? • Who is using it? • How long does it take to learn and what else do we need?

19. 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.

20. Why QPR? • Each letter in QPR represents an ideaand 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

21. 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 get the person to a professional

22. Who is using QPR? • Since 1998, nearly 3 million people have been trained in QPR • 500+ colleges and universities • Schools, law enforcement, 1st responders, counselors, clergy, school teachers, coaches, members of the military, businesses, hair dressers, bar tenders, lay citizens of every kind, and dozens of professional groups… • QPR training will be part of a new Boy Scout Merit Badge in Mental Health (in development).

23. Theory • QPR is theory-based • Recognizes that even socially isolated suicidal individuals (including farmers and ranchers) have contact with potential rescuers • QPR reaches out to high-risk people within their own environments and does not require suicidal people to ask for help.

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

25. QPRPREVENTION STRATEGY AWARENESS SURVEILLANCE DETECTION Suicidal Thoughts Suicidal Warning Signs Suicide Attempt Suicide injury or death INTERVENTION OPPORTUNITIES Perceived Insoluble Problem Question Refer Persuade Treat

26. Who to train in QPR to prevent farmer/rancher suicide? • Answer: Those who know, love, and care for them… family and friends… • Medical providers, including dentists • Bankers or financial counselors • Farm implement dealers, chemical sales persons, or anyone with whom he or she has an ongoing relationship

27. Identify the farmer’s social networkDefined in three questions: • 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? • Source: Sarason et. al., 1983.Social Support Scale

28. Our window of opportunity * Most suicidal people send warning signs * Warning signs can be taught * Gatekeepers can be trained to a) recognize suicide warning signs and, b) intervene with someone they know * Gatekeepers must be fully supported by community-based mental health providers

29. To whom are suicide warning signs sent and in what form? Suicide warning signs from farmers may: • Be direct, un-coded, and easy to interpret • Be indirect , coded, and difficult to interpret • Sent to some in the social-business network, but not others • Not be sent to care providers; thus screens/probes are required by health professionals

30. Suicide warning signs • Clear to friend: “I’m going to kill myself.” • Coded to son: “Don’t be surprised if I die in a tractor rollover.” • Clear to banker: “If you foreclose, you’ll be seeing my obit next week.” • Coded to friend: “If I should pass away, I want you have my old Winchester 12-guage.” Note: There is no published research on suicide warning signs from famers, but these are some we have collected from friends.

31. Who do famers send suicide warning signs to? Family – friends – health care professionals – bankers – veterinarians – clergy - business people with whom they interact within their social network. The following schematic helps describe who could/should be trained in QPR…

32. Suicidal network communications Adult Son Doctor Scenario: 65-yr-old famer in crisis over pending foreclosure and onset of depression – with marital problems. Suicide warning signs sent to network. Coded Clues Coded Clues Older farmer in crisis Adult daughter Coded Clues No Clues Friend Coded Clues No Clues Clear Verbal Threats & Uncoded Clues Banker Pastor Consultation • Self-referral unlikely • Hotline call unlikely • Intervention unlikely Wife Source: Paul Quinnett, Ph.D., QPR for Suicide Prevention

33. More suicide warning signs examples… • To doctor: “Is this enough medicine to kill someone?” (indirect/coded). • To dentist: “When I can’t sleep like this, I don’t give a shit about life.” (indirect/coded) • To adult son: “I’m going to be leaving you nothing I’m afraid, just my burdens.” (indirect/coded) • To adult daughter: “ You’ll need to look after your mother when I’m gone.” (indirect/coded) • To a best friend and pastor: No warning signs sent • To his wife: “Why don’t I just shoot myself and let the bank have this place?” (direct/un-coded)

34. Traditional Gatekeeper Network QPR Trained Non-trained Adult son Doctor Scenario: 65-yr-old farmer in crisis over pending foreclosure and onset of depression – with marital problems. Coded Clues Coded Clues Older farmer in crisis Adult daughter Coded Clues No Clues Friend Coded Clues No Clues Clear Verbal Threats & Uncoded Clues Medical and clergy Banker (maybe) Pastor Consultation • Nurse • Clergy person • Family doctor • Self-referral unlikely • Hotline call unlikely Wife Source: Paul Quinnett, Ph.D., QPR for Suicide Prevention

35. Unique Farmer Gatekeeper Network QPR Trained Not trained Adult Son doctor Scenario: 65-yr-old farmer in crisis over pending foreclosure and onset of depression – with marital problems. Coded Clues Coded Clues Older farmer in crisis Adult daughter Coded Clues No Clues Friend Coded Clues No Clues Clear Verbal Threats & Uncoded Clues QPR Enhanced Intervention Opportunities Banker Pastor Consultation • Adult son • Adult daughter • Wife • Self-referral unlikely • Hotline call unlikely Wife Source: Paul Quinnett, Ph.D., QPR for Suicide Prevention

36. Everyone trained – everyone rallies to help QPR Trained – wife, friends, business folks, etc. Additional Resources Daughter Son Doctor Son applies QPR confirms intent Farmer out of Crisis QPR Intervention Support Group? Referral Referral Online help Son confers with QPR-trained pastor and doctor, gets mood disorder diagnosed and treatment started…farmer social supports activated, isolation decreases, hope restored… with suicide attempt averted Pastor Mortgage help Source: Paul Quinnett, Ph.D., QPR for Suicide Prevention

37. Who to train to detect farmers at risk of suicide? • Ask 3 questions to determine social network to be trained • Determine frequency of communications – (next slide) and include email/text based relationships, e.g., grandchildren • Secure permission to train • Train as many of those willing as possible

38. Probability of intercepting a suicide warning sign? • Detection is a function of frequency of observation: Who is a dailyobserver? Who is a weeklyobserver? Who is a monthlyobserver?

39. Suicide crisis survival depends on…. • Trained gatekeepers who are frequent observers within the farmer’s social network, inclusive of: - Friends and family members - Treatment professionals - Business partners, clergy, and anyone whom the farmer interacts – implement dealers, ag-business folks, and financial professionals.

40. Farmers are not stubborn; they are farmers and … • Raised as independent persons able to care for self and others, and even to “feed the world.” • Trained in self-sufficiency and self-reliance, which means that to ask for help is a sign of weakness • Having suicidal thoughts is a stigma; a stigma they will apply to themselves!

41. Males in general and farmers/ranchers in particular…. • May wait until symptoms are debilitating before accepting help, and may never pick up the phone to make an appointment – especially if they become suicidal • Are least likely to ask for help when they most need it - but they will communicate their distress!

42. Reasons offered by males for not asking for help? • Lack of time (mental health appointments take an hour + there is a lot of travel time from the farm to the city to make that appointment). • You have to say what’s wrong • You have to tell a woman (most therapists are women) • 90% of men who get help are influenced by a significant other (friend or family) –

43. QPR theory applied to farmers • Assumption: passive systems don’t work - Farmers most at risk for suicide: - tend not to self-refer for treatment - tend to be treatment resistant - often abuse drugs and/or alcohol - dissimulate their level of despair - go undetected - go untreated (and remain at risk for suicide)

44. QPR Research Results • Increased knowledge, confidence and gatekeeping skills • Increased declarative knowledge • Increased perceived knowledge • Increased self-efficacy • Increased diffusion of gatekeeping training information • Increased gatekeeper skills (ability to engage in active listening, ask clarifying questions, make an appropriate referral) • Source:Cross, W.F., Seaburn, D., gibbs, D., Schmeelk-Cone, K. et al. (2011);Matthieu, M.M., Cross, W., Batres. A.R., Flora et al. (2008); Wyman, P.A., Brown, C.H. Inman, J., Cross W., et al (2008). • Methods: Three randomized studies conducted in school, outpatient and workplace settings examined the impact of the Question, Persuade, Refer (QPR) training on stratified samples of (1) 340 teachers and parents in a US public school community and (2) 602 community based counseling center staff from the US Department of Veteran Affairs. One study included a 1-year average follow-up assessment and a second study included a 3-month follow-up assessment. • Results: Findings reported an immediate increase in declarative knowledge, perceived knowledge, self-efficacy, diffusion of gatekeeping training information, and gatekeeping skills. Results persisted in the 3-month and 1-year follow up with marginal decrements.

45. Community strategies for farmers and ranchers … • You can’t help those you can’t serve • Train loved ones in QPR – whole farm families • Invite farmers to take training to HELP OTHER FARMERS (and they will help themselves) • Offer web-based seminars on farm stressors, common problems, offer support, and teach what depression looks and feels like • Find “farmer friendly” mental health professionals and establish online “preferred provider” resources

46. Strategies continued… • Train farm community stakeholders as gatekeepers to identify and refer farmers and their family members to “farm friendly” service providers – grocers, barbers, pharmacists, vets, hardware dealer staff, dentists, and others… • Work with your local newspapers to run positive stories on farm life and challenges, and run side bars of common psychological problems encountered by farmers and how to access services.

47. Leverage the web • Farmers and ranchers have access to the internet • Online QPR training is available at low cost • Professionals who serve farmers and ranchers need training in suicide risk detection, assessment, treatment and management – and this training is online as well… • Consider online counseling (text, Skype, phone) – confidential, accessible, affordable, available… Bandwidth reduces isolation!

48. Shame and suffering… “To farmers, ‘the land is everything.’ Ownership of a family farm is the triumphant result of the struggles of multiple generations. Losing the family farm is the ultimate loss – bringing shame to the generation that has let down their forbearers and dashing the hops for successors.” Rosmann, 2003.

49. Times are changing • Suicide is now preventable • Everyone is responsible to take action to prevent a death, including by suicide • Suicidal thinking and planning often precede not only violence to self but others. Thus, preventing suicide prevents other forms of violence.

50. Education and training options • Expert-led classroom multi-media • Interactive • Short video lectures only • Game maze learning • Practice sessions • Blended online + classroom led practice sessions, referral networks, internal and external supports and how to use them