WELCOME

1. WELCOME COLORADO EMS SUICIDE PREVENTION SPECIALIST TRAINING

2. Before we get started I want you to check out the 3 people sitting nearest to you.

3. Introduction Depending on your relationship with those being trained, I would recommend a brief introduction of yourself. I like to answer the questions; “Who is the person standing up there training me?” “Why should I believe him/her?” “What does he/she have to teach me and where did they acquire this information?”

4. Take Out Your Packets Just Like It’s Your Birthday!

5. Taking Care of Yourself. • Suicide is personal • Many of you may be survivors • Some may be attempt survivors • This training can be difficult • Take care of yourself during this training.

6. Raise your hand if…Wait until all questions asked • Have you ever thought about suicide? • Do you know someone who has? • Do you know anyone who has made a suicide attempt, • or even died by suicide? • Are you worried, right now, that someone you know is thinking about suicide?

7. Prerequisite online learning QPR Gatekeeper for Suicide Prevention Certificate Understand suicide as a major public health problem Name major suicide prevention organizations and access their web sites Recognize someone at risk of suicide Recognize at least three suicide warning signs

8. Demonstrate increased knowledge, skill and self-efficacy in the application of the QPR Know how to engage and assist a suicidal colleagues or co-worker Understand the common myths and facts surrounding suicidal behavior Describe and name multiple local or state referral resources Understand means restriction and how to immediately reduce risk

9. Recognize and identify at least three risk factors for suicide Recognize and identify at least three protective factors against suicide Understand the nature of suicide Engage in an interactive and helpful conversation with someone who has attempted suicide Engage in an interactive and helpful conversation with the loved ones or family members of someone who has died by suicide

10. Classroom learning goals Understand risk factors and warning signs associated with suicide Understand the nature of suicide Recognize risk factors associated with exposure to trauma Understand the need for and identify various strategies for self-care

11. Respond to suicide attempt survivors Help suicide survivors (family members left behind) Help fellow EMS providers who may be having suicidal thoughts Identifying local and national suicide prevention resources

12. Clump Up • Why you are here • What has your experience taught you • Share what you learned from the online material • What do you still want to know • About suicide • About teaching this material

13. Training others to be EMS Suicide Prevention Specialists (EMS SPS) The minimum training required to be awarded an EMS SPS certificate is five (5) hours The course can be taught entirely by the Instructor using the materials and audio visual aids, provided the EMS SPI is also a QPR Certified Gatekeeper Instructor.

14. If not a QPR Certified Instructor, those earning a certificate as an EMS Suicide Prevention Specialist must complete • Minimum of two (2) hours of online training • Minimum of three (3) hours of classroom training • Pass all online and classroom quizzes and exams as determined by the EMS SPI • Participate in role-plays and exercises • See sample training schedule in packet

15. QPR Institute Training for Everyone • To create safer communities means training at all levels: - QPR Citizen Gatekeeper Training and Instructor Certification Course - QPR Suicide Triage Training and Instructor Training Course for 1st responders (e.g., QPR for EMS) - QPRT Suicide Risk Assessment training for health care professionals - QPRT for physicians and nurses

16. QPR Colorado EMS SPSClassroom Training

17. Classroom Material Schedule Introduction and overview Brief review of QPR and online materials Suicide in Colorado Understanding Suicide Local Resources Role-plays Self care

18. Suicide in Colorado 34,598 suicide in United States in 2007 Or 94.8 a day for a rate of 11.5 811 suicides in Colorado in 2007 Or 2.2 a day for a rate of 16.7 Colorado ranked 6th in 2007 Up from a ranking of 9th in 2006

19. In Colorado in 2006 722 people died by suicide 198 people died of homicide or a legal intervention 10 children age 4 or younger were a victim of homicide 7 people died of unintentional firearm injuries Suicide is the second leading cause of death and homicide is the third leading cause of death for young Coloradans ages 15-34.

20. Colorado Suicide 1999 - 2005

21. UNDERSTANDING SUICIDE Provide a leading theory to better understand suicide Teach the three necessary conditions for a suicide event to occur Demystify and de-stigmatize suicide by bringing the behavior into the range of understandable human behavior

22. Underlying Principles Suicide is not the great mystery that it has been made out to be. The basic components of suicide are knowable. When we understand these components we can act with more confidence. Informed interventions save lives.

23. Suicidal Behavior • Means someone is in extreme pain and suffering • Means complex feelings and behavior • Involves many reasons and factors • Means coming at it from many directions • This training is just one those directions

24. Nature of suicide and Joiner’s new theory… • Psychic suffering (Psyche-ache) • Hopelessness • Unbearable mental anguish • Cognitive constriction • Grossly impaired problem solving ability • Feeling a burden to others • Thwarted belongingness • Acquired capacity for self-injury and habituation to pain T. Joiner, Why People Die by Suicide, 2006

25. Understanding Suicide Based on the work of Thomas Joiner, PhD and his book Why People Die by Suicide

26. Underlying Principles Suicide is not the great mystery that it has been made out to be The basic components of suicide are knowable When we understand these components we can act with more confidence Informed interventions save lives It’s what we don’t know that we don’t do, and what we don’t do costs us lives unnecessarily lost.

27. Basics of Suicide and Serious Attempts • Two major components associated with suicide and serious attempts • The desire to die and • the capacity for self harm • Two elements within the desire to die • Perceived burdensomeness • A sense of thwarted or low belongingness

28. Sketch of the Theory Those Who Desire Suicide Those Who Are Capable of Suicide Serious Attempt or Death by Suicide

29. Acquired Capacity for Suicide Suicidal behavior is not just about the desire to die It requires the capacity to inflict self injury

30. The Acquired Capability to Enact Lethal Self-Injury • This capacity is acquired over time • Accrues with repeated and escalating experiences involving pain and provocation, such as • Past suicidal behavior, but not only that… • Repeated injuries • Repeated witnessing of pain, violence, or injury (i.e.. physicians, EMS, ED nurses, and law enforcement personnel) • Any repeated exposure to pain and provocation.

31. The Acquired Capability to Enact Lethal Self-Injury According to Joiner, with repeated exposure, one habituates – the “taboo” and prohibited quality of suicidal behavior diminishes, and so may the fear and pain associated with self-harm

32. What do tattoos mean?

33. Tattoos and Suicide In a case-controlled study comparing accidental deaths to suicides, people who died by suicide were more likely to have tattoos (Dhossche, Snell, & Larder, 2000). Could it be that the eventual suicide victims obtained increased capacity for suicide partly via painful and provocative experiences, such as tattooing, piercing, etc.?

35. Deliberate self-harm and suicide Evidence: - People who have experienced or witnessed violence or injury have higher rates of suicide – prostitutes, self-injecting drug abusers, people living in high-crime areas, physicians - Those with a history of suicide attempt have higher pain tolerance than others

36. Components of the Desire for Death Perceived Burdensomeness Thwarted Belongingness

37. Perceived Burdensomeness Feeling ineffective to the degree that others are burdened is among the strongest sources of all for the desire for suicide

38. Suicide lightens the load the rest of us carry…. Research: Brown, Comtois, & Linehan (2000) reported that genuine suicide attempts were often characterized by a desire to make others better off, whereas non-suicidal self-injury was often characterized by desires to express anger or punish oneself …

39. Thwarted or Low Belongingness The need to belong to valued groups or relationships is a powerful, fundamental, and extremely pervasive human motivation When this need is thwarted, numerous negative effects on health, adjustment, and well-being have been documented

40. Thwarted Belongingness The need to belong is so powerful that, when satisfied, it can prevent suicide -- even when perceived burdensomeness and the acquired ability to enact lethal self-injury are present… By the same token, when the need is thwarted, risk for suicide is increased

41. Thwarted Belongingness: Empirical Evidence Hoyer and Lund (1993) studied nearly a million women in Norway; over the course of a 15-year follow-up, over 1,000 died by suicide They reported that women with six or more children had one-fifth the risk of death by suicide as compared to other women

42. Thwarted or Low Belongingness The need to belong to valued groups or relationships is a powerful, fundamental, and extremely pervasive human motivation. When this need is thwarted, numerous negative effects on health, adjustment, and well-being have been documented.

43. Those Who Desire Suicide Perceived Burdensomeness Those Who Are Capable of Suicide Thwarted Belongingness Serious Attempt or Death by Suicide

44. Prevention/Treatment Implications The model’s logic is that prevention of “acquired ability” OR of “burdensomeness” OR of “thwarted belongingness” will prevent serious suicidality Increasing belongingness may be the protective factor one can influence the most and quickest Example PSA: “Keep your old friends and make new ones – it’s powerful medicine”

45. Questions and discussion?

46. RESPONDING TO SUICIDAL PEOPLE AND THEIR LOVED ONES The following structured interactive discussion session is intended to assist you by reviewing the training received online in this area. Through role-plays you can practice and share strategies for dealing with those who have attempted suicide and the families and loved ones of both attempt survivors and those who complete suicide

47. Finally this section is to minimize your experience of secondary trauma in responding to suicide events.

48. Review Being emotionally present Accurate empathy Genuineness Unconditional positive regard (NO Judgment!) Active listening Reflecting Open ended questions Problem solving Plan of Action

49. The definition of few terms Survivors of suicide: • Committed suicide • He took his own life • She ended her own life • She died by suicide

50. First responders may face any of the three following scenarios: A person who may be suicidal and have recognized warning signs A person who has just attempted suicide or attempted in recent past Family, friends of someone who has attempted suicide or dies by suicide